NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION VALUE

DIAGNOSIS ANALYSIS INTEGRATION

Objective cues: Deficient fluid A woman is General: 1. Assessed 1. To evaluate After 6 hours Time and effort
- edema volume said to be After 6 hours patient’s vital signs degree of fluid deficit. of nursing of the nurse to
formation on related to preeclamptic of nursing (BP, temperature, interventions, listen.
the extremities protein loss as when her BP interventions, PR, and RR) and patient was
evidenced by rises, taken on patient will: noted strength of able to attain Patience of the
- visual edema, visual two occasions peripheral pulses. normal nurse because
changes changes, and at least 6 a.) be able to -Independent conditioning, objective is not
dry mouth hours apart. know the nursing intervention participated in easily met.
- dry mouth with cracked The diastolic causative the actions
and cracked lips. value of BP is factors that 2. Observed 2. To more which Willingness of
lips extremely affects the urinary output, accurately determine improved the patient to
important to sudden color, and replacement needs. body’s normal reduce
document increase of BP measured amount fluid volume, uneasiness.
because it is during and specific gravity. and was able
this pressure pregnancy. Measured or to know the Willingness of
that best estimated other causative the nurse to
indicates the b.) fluid losses. factors that help the patient.
degree of demonstrate a -Inependent affect high BP.
peripheral positive nursing intervention
arterial spasm attitude
present. In toward the 3. Reviewed 3. To evaluate
addition to the nurse’s laboratory data. degree of fluid deficit.
hypertension teachings. -Collaborative
a woman has nursing intervention
proteinuria
(1+ or 2+ on
a reagent test Specific: 4. Evaluated 4. To assess
strip on a Within 6 hours nutritional status, causative/precipitating
random of nursing noted current factors.
sample). interventions, intake, weight
Many women patient will: changes, and
show a trace problems with oral
of protein a.) maintain intake.
during fluid volume -Independent
pregnancy. at a functional nursing intervention
Actual level.
proteinuria is 5. Provided 5. To correct or
said to exist b.) attain nutritious diet via replace fluid losses to
when it stable vital appropriate route; reverse
registers as at signs. gave adequate free pathophysiological
least 1+ or water with enteral mechanisms.
more (this c.) have moist feedings.
represents a mucous -Dependent nursing
loss of 1g/L). membranes. intervention
Edema
develops 6. Bathed less 6. To maintain skin
because of the frequently using integrity and prevent
protein loss, mild cleanser/soap, excessive dryness.
sodium and provided
retention, and optimal skin care
lowered with suitable
glomerular emollients.
filtration rate. -Independent
Edema begins nursing intervention
to accumulate
in the upper 7. Provided 7. To prevent injury
part of the frequent oral care. from dryness.
body, rather -Independent
than just the nursing intervention
typical ankle
edema of 8. Discussed 8. Early identification
pregnancy. factors related to of risk factor can
occurrence of decrease occurrence
Source: deficit, as and severity of
Maternal and individually complications
Child Health appropriate. associated with
Nursing (5th -Independent hypovolemia.
edition, p. nursing intervention
427)
-Adelle
Pillitteri 9. Instructed to 9. Alcohol or
limit intake of caffeinated beverage
alcoholic/caffeinated tends to exert a
beverages. diuretic effect.
-Independent
nursing intervention
10. Changed 10. To promote
position frequently. comfort and safety.
-Independent
nursing intervention
ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION VALUE
DIAGNOSIS ANALYSIS INTEGRATION

Subjective cue: Decreased With General: 1. Monitored 1. Comparison After 6 hours of Willingness of
“Nabantayan cardiac output hypertension, the After 6 hours of blood pressure of of pressures nursing the patient to
nako nga related to cardiac system nursing the patient. provides a more interventions, attain normal
murag nikalit decreased can become interventions, Measured in both complete picture patient was able conditioning.
lang ug dako venous return. overwhelmed the patient will arms or thighs of vascular reduce blood
akong timbang” because the heart reduce blood three times, 3-5 involvement or pressure or Determination of
as verbalized by is forced to pump pressure or minutes apart scope of the cardiac workload the nurse to
the patient. against rising cardiac while patient was problem. and was able to help the patient
peripheral workload. at rest, then identify the improve and
Objective cues: resistance. This seated, then signs of cardiac achieve optimal
- variations in reduces the blood Specific: stood for initial decompensation. level of health.
blood pressure supply to organs, After 6 hours of evaluation.
most markedly nursing -Independent Patience
- edema on the the kidney, interventions, nursing because
extremities pancreas, liver, the patient will intervention objective is not
brain, and be able to easily met.
- vital signs placenta. Poor identify the 2. Observed skin 2. Presence of
taken as placental signs of cardiac color, moisture, pallor, cool, skin
follows: perfusion may decompensation. temperature, and moist, and
BP= 150/120 reduce the fetal capillary refill delayed capillary
mmHg nutrient and time. refill time may
oxygen supply. -Independent be due to
PR= 96 bpm Another effect is nursing peripheral
that arterial intervention vasoconstriction.
RR= 24 cpm spasm causes the
bulk of the blood
T= 36.6 C volume in the 3. Noted 3. May indicate
maternal dependent or heart failure,
circulation to be general edema. renal or vascular
pooled in the -Independent impairment.
venous nursing
circulation, so a intervention
woman has a
deceptively low 4. Implemented 4. These
arterial dietary sodium, restrictions can
intravascular fat, and help manage
volume. In cholesterol fluid retention
addition, restrictions as and with
thrombocytopenia indicated. associated
or a lowered -Collaborative hypertensive
platelet count nursing response, which
occurs as intervention decrease cardiac
platelets cluster workload.
at the sites of
endothelial 5. Avoided the 5. To
damage. use of restraints. minimize/correct
May increase causative
Source: agitation and factors,
Maternal and increase the maximize
Child Health cardiac workload. cardiac output.
Nursing (5th -Independent
edition, p. 426) nursing
-Adelle Pillitteri intervention
6. Maintained 6. Reduces
activity physical stress
restrictions. and tension that
-Independent affect blood
nursing pressure and
intervention course of
hypertension.

7. Instructed in 7. Can reduce

relaxation stressful stimuli,
techniques, and produce calming
guided imagery. effect thereby
-Independent reduce blood
nursing pressure.
intervention

8. Provided 8. Help reduce

calm, restful sympathetic
surroundings, stimulation,
minimized promotes
environmental relaxation.
noise.
-Independent
nursing
intervention

9. Provided for 9. To promote

adequate rest, venous return.
positioned patient
for maximum
comfort.
-Independent
nursing
intervention

10. Gave 10. Provides

information about encouragement
positive signs of and promotes
improvement, wellness.
such as
decreased
edema, improved
vital
signs/circulation.
-Independent
nursing
intervention
ASSESSMENT NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION VALUE
DIAGNOSIS ANALYSIS INTEGRATION

Vital signs Ineffective Increased cardiac out General: 1. Monitored 1. For After 6 hours Time and effort
taken as tissue perfusion put that injures those After 6 hours blood pressure baseline of nursing of the nurse.
follows: related to endothelial cells of the of nursing every 2 hours. information. interventions,
vasoconstriction arteries and the action interventions, -Independent patient was Eagerness of
BP= 150/120 of blood of prostaglandins. the patient will nursing able to know the patient to
mmHg vessels. Vasoconstriction be able to intervention the factors that achieve normal
occurs and blood know the affect her state.
PR= 96 bpm pressure increases. factors 2. Determined 2. To note condition,
affecting her presence of degree of verbalized Willingness of
RR= 24 cpm Source: condition. visual, impairment or understanding the nurse to
http://nursingcrib.com sensory/motor organ of condition, impart
T= 36.6 C / vasoconstriction-of- Specific: changes, involvement. and knowledge and
blood-vessels/ After 6 hours headache, demonstrated being certain in
of nursing dizziness, altered behaviors that the
interventions, mental status, improved interventions.
the patient will personality circulation.
be able to changes.
verbalize -Independent
understanding nursing
of condition intervention
and
demonstrate 3. Instructed to 3. Sodium
behaviors to eat low and salt tends to be
improve low fat diet. excreted at a
circulation. - Independent faster rate.
nursing
intervention

4. Administered 4. To control
anti-hypertensive the blood
drug prescribed pressure and
by the physician. to avoid other
-Dependent complications.
nursing
intervention

5. Noted reports 5. To note

of degree of
nausea/vomiting. impairment.
-Independent
nursing
intervention

6. Encouraged 6. To
discussion of promote
feelings wellness.
regarding
prognosis/long-
term effects of
the condition.
-Independent
nursing
intervention
7. Referred to 7. Promotes
specific support wellness.
groups,
counseling, as
appropriate.
-Collaborative
nursing
intervention

8. Evaluated 8. To know
vital signs, noted whether
changes in BP, patient’s
heart rate, and condition has
respirations. changed or
-Independent not.
nursing
intervention

9. Evaluated for 9. To assess

signs of infection, causative or
especially when contributing
immune system factors.
is compromised.
-Independent
nursing
intervention

10. Encouraged 10. Enhances

ambulation when venous return.
possible.
-Independent
nursing
intervention